Welcome to the new NHS

Austerity and rationing: two words which are strongly reminiscent of Second World War years. However, add to them the phrases postcode lotteries, cut-backs, and year-on-year savings and one is rapidly brought into the modern day. A further phrase, the ‘Nicholson Challenge’, is one more familiar to those working within the National Health Service; nonetheless, it has the power to impact upon us all. For the NHS, the Nicholson Challenge is a descriptive phrase that sums up the biggest ‘efficiency drive’ in its entire history.

By the year 2015, the NHS is expected to have found at least £20 billion in savings. At present, that means reducing budgets by 4% per year. In an organisation that is already struggling to meet demands for health care for an increasingly aged population, incorporate the latest treatments, allow access to new drugs, and extend provision of trained staff (e.g. consultant cover at weekends), the savings are not easy to come by. To a great extent, that has been a driving force behind the new Health and Social Care Act; the remorseless reduction in administrative personnel (by closing Primary Care Trusts) and the drive to increase the managerial input from GPs.

‘Putting GPs in the driving seat’ may seem like a catchy, vote-winning strap-line to the latest reforms; in reality, it is ‘GPs in the firing line’. Those difficult decisions about whether a new drug or service can be offered to patients will now need to be taken by your GP through an organisation called the Clinical Commissioning Group (CCG). Many patients will understandably think that is good on the grounds that doctors are supposed to act in the best interests of the patients. The problem for GPs is that, in today’s austere financial climate, restrictions on prescribing have probably never been so great, and they are going to get worse. As a professor of public health research and policy recently told a conference of doctors, ‘you haven’t got any idea what is coming your way; it’s goodbye to professional autonomy’.

The latest news from the Department of Health is that the 4% efficiency drive will need to continue beyond 2015, which means a downward pressure on GP drug budgets for a decade. It is therefore understandable that CCGs greet the arrival of new drugs with dismay rather than clinical excitement. The situation is not helped by the NHS Constitution stating that ‘patients have the right to drugs recommended by NICE for use on the NHS, if your doctor says they are clinically appropriate’. Unfortunately for GPs, NICE (the National Institute for Clinical Excellence) makes its decisions on the grounds of drug effectiveness, not whether the NHS budget can afford it.

One recent example has been paraded widely in the national press. Dabigatran is a new drug that may offer an alternative to warfarin therapy for conditions such as deep vein thrombosis. In many ways, this would offer several advantages to patients and doctors. However, the price tag is steep. It has been estimated that its use will force drug costs up by 20% (£10 million pounds per year in some areas of the country). Set against the need for 4% savings, such a threat to the drug budget is causing widespread alarm, and CCGs are desperately looking at local prescribing policies in order to restrict the use of dabigatran.

The Health and Social Care Act may be here and GPs may well be in the driving seat, but the NHS is on a one-way track; attempts to turn it are equally likely to derail it and now that will be the doctors’ fault, not the politicians’ doing. The danger of failure is the imposition of large corporations in providing commissioning support, with private control of prescribing and referrals; welcome to US-style medical care.

There can be little doubt left that, as GPs, we are now firmly placed between that proverbial ‘rock and a hard place’.

(First published in the Scunthorpe Telegraph, Thursday, 12^th April 2012)

Is the NHS now on Death Row?

At the time you read this column it will be just over one month since the Health and Social Care Bill was passed by the House of Commons. It may be that the Queen has since added her signature and this badly thought-through piece of legislation has taken its place within the laws of our land, despite the collective opposition of most senior health colleges and organisations. Castigated by many for my early, publicly expressed opposition to the proposals, I am now metaphorically deafened by those who have awoken too late in the day to the reality of the destruction to the integrity of our National Health Service that this political axe now threatens.

However, we are where we are and, as with all previous NHS upheavals, those who are already tasked with providing the majority of the health care in this country will roll up their sleeves and try to make a silk purse out of a sow’s ear. I speak, of course, of the General Practitioners; those without whom the foundations of the NHS would simply crumble. I say that, not because I am a GP, but because it is a fact that 80% of health care is performed in General Practice. We are, in effect, the front line of the health service.

That said, it will probably come as no surprise to you if I say that the front line is under siege. The pressures on general practices around the country are already overwhelming, and the bad news is that it is about to get worse. If you have difficulty in getting an appointment to see your GP, thank the government for the mess they have created for us all. Not only are GPs already having to spend many more hours per week in running the health service (not forgetting that the Government shamelessly started to dismantle Primary Care Trusts even before the Bill was passed by Parliament), but a lack of investment in General Practice has left it in a perilous state, with smaller practices facing the potential prospect of closure, and larger practices having difficulty in recruiting new doctors as partners or associates. Even locum doctors are a fast disappearing commodity.

Across the country, an additional man-power crisis is looming. 10% of GPs are over the age of 60. In London, the figure rises to 38%, and in the West Midlands it is around 17%. Coupled with that, many GPs in their 50s are looking to an earlier retirement than previously planned; mainly as a direct result of the effect of Government policies on workload, reduction in primary care funding, excessive taxation and unwarranted meddling with pensions. However, recruitment to general practice has been flat since 2010 (running at a ‘growth’ of 0.2%). With the deepest of respect you, as patients, can complain all you like to our practice managers, and we as doctors can say ‘sorry’ as often as you can stand hearing it. However, without significant re-investment and the instigation of an immediate policy for creating more GPs, the situation is only going to go from bad to worse. As it is, general practice as you know and desire it to be is not presently sustainable for the longer term. In truth, the cynics amongst us wonder if that is really the Government’s ulterior motive. The Secretary of State for Health has now won his way; the question is at what future cost to the health of us all?

(First published in the Scunthorpe Telegraph, Thursday, 5th April 2012)